Failure to Maintain Complete and Accurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the medical records for two residents. For one resident with diagnoses including cancer, wound infection, diabetes, and arthritis, there was a lack of documentation and assessment regarding significant bruising and an open area on the upper arms. Despite physician orders requiring daily skilled notes and monitoring for bruising, the medical record did not include specific assessments, measurements, or descriptions of the bruises or the open area. Progress notes, daily skilled notes, and skin and wound evaluation forms repeatedly omitted mention of these issues, and there were no treatment instructions for the open area. Interviews with nursing staff and the DON confirmed that the bruising and open area were not documented as required, and that the facility lacked a policy on complete and accurate documentation. For another resident receiving diuretic therapy for heart failure, the facility failed to accurately document medication administration in accordance with physician orders that required holding the medication if the resident's weight fell below a certain threshold. The medication administration records (MAR) showed that the resident received the diuretic multiple times when their weight was below the specified limit. Interviews with nursing staff and the nurse practitioner confirmed that the medication should have been held and not administered, as the resident's weight had consistently been below the threshold since admission. There was also confusion among staff regarding documentation codes on the MAR, with one LPN incorrectly interpreting staff initials as an indication that medication was not given, when in fact it was. Additionally, the facility did not provide a policy for medication administration when requested, and the DON confirmed that there was no record of non-narcotic medication wastage, despite staff claims that medication was wasted when not administered. The lack of accurate documentation and failure to follow physician orders for medication administration and skin assessments led to incomplete and inaccurate medical records for both residents.